Content created by Office of Medicare Hearings and Appeals (OMHA)
The current Medicare appeals process was established by various statutes and implementing regulations. The table below lists some of the statutes and regulations that govern the appeals process for Medicare claims and entitlement, Medicare Advantage organization determination, and Medicare prescription drug coverage determination appeals, as well as select OMHA and Centers for Medicare & Medicaid (CMS) program guidance.
*Statutory citations are given to the Social Security Act, as amended, with United States Code (U.S.C.) equivalents as parentheticals. However, please note that the online version of the U.S.C. may be more current than the online version of the Social Security Act.
The CMS Administrator also issues Rulings that serve as precedent final opinions and orders and statements of policy and interpretation. CMS Rulings are binding on all CMS components and OMHA adjudicators.
The Chair of the Departmental Appeals Board (DAB) may designate certain Medicare Appeals Council decisions as precedential. These precedential decisions are binding on all HHS components, including OMHA adjudicators.
With the exception of CMS Rulings, the legal authorities on this page address only the Medicare appeals process. Other statutes, regulations, and program guidance address Medicare coverage and payment rules. For general information about the items and services that Medicare covers, please visit the portion of the Medicare.gov website entitled What Medicare Covers. For general information about Part C Medicare Advantage plans, visit this page. For general information about Part D prescription drug plans, visit this page.